=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174024210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY HOME CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2018
-----------------------------------------------------
Last Update Date | 03/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 734 ROBIN HOOD DR
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31313-3985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-738-8688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 734 ROBIN HOOD DR
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31313-3985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-738-8688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | MISS KERLLANNE OCCEUS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 239-738-8688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 089-R-1894
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------